Tertiary Survey for Trauma Patients

The purpose of the tertiary survey is to avoid missed injuries in trauma patients. All trauma patients should undergo tertiary surveys ideally within 24 hours of admission. Since patients who remain sedated, altered, or critically ill are at increased risk for missed injury, these patients should have their tertiary survey repeated once their ability to report focal tenderness becomes reliable.

The trauma day intern is responsible for ensuring that tertiary surveys have been completed for all recently admitted patients. When the trauma day intern has a day off, tertiaries are the responsibility of the intern covering swing. Medical students may assist with tertiary surveys and may write tertiary notes based on the template below but the physical survey and other findings must be confirmed by the intern and the intern must co-sign the tertiary survey note. The geriatric trauma nurse practitioner rounding with the team will assist with orienting interns to the tertiary survey process.

In the TICU or SICU, the ICU fellow is responsible for ensuring that tertiary surveys are completed. When a patient is transferred from ICU level of care to IMCU or med-surg, tertiary surveys should be repeated and documented by the intern covering the patient’s primary service.

Tertiary surveys should also be performed prior to discharging patients to home from the trauma resuscitation unit (TRU). The resuscitation resident is responsible for performing and documenting tertiary surveys for patients discharged from the TRU. Any new findings should be reviewed with the attending on call.

• Review of prior imaging and final interpretations
• Review of recent labs
• Head to toe physical survey with attention to new areas of concern (the template below can be used as a checklist for physical survey as well as for documentation)
• Plan: New imaging ordered, new consults placed

Tertiary surveys should be documented in a separate note (not as part of an H and P or progress note).  The note type should be “Surgical Progress Note”, select the template “Free Text Note”, and change the title to “Tertiary Survey.”  Once the note is open, use the template below.  This template can also be used to create a dot phrase for ease of use.   Tertiary notes do not need to be forwarded to an attending for co-signature.

Sample Template of Tertiary Survey Note (must be edited to reflect any positive findings):

Subjective complaints:
No pain or other complaints aside from appropriate level of discomfort associated with previous known injuries.

Physical Exam:
Neurologic: GCS 15 (E4 V5 M6), no focal motor or sensory deficits
Head and Neck
Scalp: no lacerations, bruising, or swelling
Facial bones: no instability, bruising, or swelling
Eyes: PERRLA, EOMI
Ears/Nose: no bleeding or clear drainage
Oral cavity: Intact dentition, no malocclusion, intact oral mucosa
Trachea: Midline, no subcutaneous emphysema
Soft tissue of neck: No ecchymosis, laceration, or swelling
Chest: No bruising, or crepitus; ribs and sternum stable with no focal tenderness or deformity
Abdomen: Soft, non-tender, non-distended, no ecchymosis or seatbelt sign
Pelvis: Intact with no crepitus or deformity, no tenderness at pubic symphysis
Extremities: No deformity or tenderness, normal range of motion, sensation and motor function grossly intact
Vascular: 2+ radial, femoral, DP/PT pulses
Back: No ecchymosis, lacerations, or abrasions
Spine: No cervical, thoracic, or lumbar tenderness

Studies:
Admission imaging with final interpretations and recent labs reviewed.
Additional imaging ordered: none
New consults placed: none

Neurologic: GCS 15 (E4 V5 M6), no focal motor or sensory deficits
Head and Neck
Scalp: no lacerations, bruising, or swelling
Facial bones: no instability, bruising, or swelling
Eyes: PERRLA, EOMI
Ears/Nose: no bleeding or clear drainage
Oral cavity: Intact dentition, no malocclusion, intact oral mucosa
Trachea: Midline, no subcutaneous emphysema
Soft tissue of neck: No ecchymosis, laceration, or swelling
Chest: No bruising, or crepitus; ribs and sternum stable with no focal tenderness or deformity
Abdomen: Soft, non-tender, non-distended, no ecchymosis or seatbelt sign
Pelvis: Intact with no crepitus or deformity, no tenderness at pubic symphysis
Extremities: No deformity or tenderness, normal range of motion, sensation and motor function grossly intact
Vascular: 2+ radial, femoral, DP/PT pulses
Back: No ecchymosis, lacerations, or abrasions
Spine: No cervical, thoracic, or lumbar tenderness